WEDI ICD-10 Testing Concerns

January 13, 2014

Dear Secretary Sebelius:

In its advisory role under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Workgroup for Electronic Data Interchange (WEDI) periodically brings to your attention issues related to healthcare information exchange and related areas that it believes merit review and consideration by the Secretary of Health and Human Services (HHS). We take this opportunity to ask you to consider additional Medicare testing prior to ICD-10-CM and ICD-10-PCS (ICD-10) implementation.

In the January 16, 2009 Federal Register (74 FR 3328), HHS published a final rule adopting the ICD-10-CM and ICD-10-PCS medical code sets as the HIPAA standards to replace the previously adopted ICD-9-CM medical code set for diagnosis and inpatient procedure coding. The compliance date established by the final rule was October 1, 2013. In the September 5, 2012 Federal Register the compliance date for this requirement was extended to October 1, 2014.

WEDI has been working with public and private sectors of the industry to facilitate implementation of ICD-10 for many years and recognizes that this change in medical code sets may be the single largest technical, operational and business implementation in the healthcare industry in the past thirty years. As such, thorough testing will be critical to avoid significant disruption to the industry.

Recently CMS announced (MLN Matters®Number: MM8465) plans for front-end ICD-10 testing between Medicare Administrative Contracts (MACs) and their trading partners and created an ICD-10 testing week to generate industry awareness and to instill confidence that CMS and the MACs are ready and prepared for the ICD-10 implementation. We agree that it is essential that MACs provide the opportunity for providers and others to submit test claims through the CEM or the DME Common Electronic Data Interchange (CEDI) during the designated testing week. We applaud CMS for this decision, but also recognize that front-end testing alone may not be sufficient.

The concept of trading partner testing was originally designed to validate the trading partners’ ability to meet technical compliance and performance processing standards during the HIPAA Version 5010 implementation. However, it was discovered that front-end testing alone did not uncover issues that arose when the transaction data was processed by downstream applications. What was thought of as a relatively simple front-end change turned out to be much more complex and it took several months to resolve implementation issues and required the government to issue two contingency plans.

Implementation of ICD-10 is much more complex than HIPAA Version 5010 or other HIPAA mandates to date. The use of diagnosis and procedure codes impacts nearly every application and business process in hospitals, physician offices and health plans, as well as vendor applications and clearinghouse functions. As such, this mandate will require the most significant testing effort to date. The following considerations entered into our decision to suggest more robust Medicare testing:

Robust testing will always occur – the question is whether it occurs prior to implementation or in production after implementation.

Issues uncovered prior to production are more easily resolved with less impact and less cost to the industry.

The single-date cutover does not allow for gradual implementation and identification of issues. Instead, issues will likely impact all trading partners at once.

A disruption to the payment process can have significant detrimental effects on providers, because if an organization cannot submit claims and receive payment for its services it cannot afford to pay its employees, vendors, etc.

Payment disruption issues have the potential of impacting access to care for Medicare beneficiaries who can least afford issues with their care or payments.

Front-end testing alone would not appear to validate processes such as cross-over or Medicare secondary claims nor will it assist providers in determining the impact of ICD-10 on reimbursement.

Testing of front end edits and formatting may not identify skewed distribution of code usage that could be detected via analysis of appropriate metrics.

Complete end-to-end testing of any technology project allows developers to ensure, as much as possible, that when the individual parts are put together, the system works as expected. IT experts concur that adequate end-to-end testing vs. testing individual steps and processes in isolation is critical to successfully implementing any major IT project.

While engaging in end-to-end testing with every Medicare provider may not be practical, we do believe there must be sufficient and robust testing with a range of trading partners –
hospitals, physicians (large and small practices from different medical specialties), clinics, clearinghouses and Medicare secondary payers. This will give the industry a higher level of confidence that the Medicare claims processing system will operate as intended when ICD-10 goes live.

Finally, we believe that it will be critical for HHS and WEDI to closely monitor both industry progress and early testing results to better gauge what might occur on October 1, 2014. WEDI appreciates the opportunity to work with your office to continue outreach efforts and to identify best approaches for achieving industry compliance.

Devin Jopp, Ed.D, President and CEO of WEDI, or I would be pleased to answer further questions.